Kansas Medicaid coverage for Ozempic (Type 2

Medicaid

Covered with requirements

What you need to qualify

Age 18 and older
Trial of metformin for at least 90 days, or a documented reason it can't be used (["contraindication", "combination_with_high_a1c"])
Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

Glycemic control in T2DM

All of:

Diagnosis of T2DM
Age >= 18 years
Prescriber provides prespecified HbA1c goal of 6.5%, 7.0%, or 8.0%
Baseline HbA1c obtained within past 6 months that is greater than the prespecified goal
Dose does not exceed 2 mg SQ weekly
Patient is not currently on a DPP-4 inhibitor
Preferred PDL drug trial completed unless non-preferred PDL PA criteria met

Plus any one of:

Adequate trial of generic metformin IR or metformin ER for at least 90 consecutive days in the past 120-day period
Prescribed generic metformin IR or ER concurrently with requested drug AND HbA1c >= 1.5% above prespecified goal
Contraindication to metformin

Documentation to bring

Prescriber-specified HbA1c goal (6.5%, 7.0%, or 8.0%)
Baseline HbA1c lab result obtained within the past 6 months showing value greater than the prespecified goal
Documentation of metformin trial (>=90 consecutive days in past 120 days), concurrent metformin prescription with HbA1c >=1.5% above goal, or contraindication to metformin
Confirmation patient is not currently on a DPP-4 inhibitor
Documentation that preferred PDL drug was tried or reason for non-preferred PA criteria

Quantity limits

0.25mg, 0.5mg, 1mg, 2mg — Max 2 mg SQ once weekly

Approval and renewal

Initial approval: 6 months
To renew, the plan looks for improvement in A1C and Renewal requires either: (1) reduction of HbA1c of at least 1% since the last approval, OR (2) achievement or maintenance of therapeutic HbA1c goal as specified on the initial request. Renewal duration is 12 months if at HbA1c goal, or 6 months if not at goal but at least 1% further reduction since last approval. Age and dosing limits must still be met.

Not covered when

Concurrent DPP-4 inhibitor use
Type 1 diabetes

Policy note: This is a Kansas Medicaid (KMAP) PA policy. The document references preferred PDL drugs; non-preferred PDL criteria may apply separately. For HbA1c >10% or glucose >=300 mg/dL, injectable therapy (GLP-1 RA or basal insulin) is recommended but not required. Maximum dose per Table 1 is 2 mg SQ once weekly. The document covers semaglutide injection (Ozempic) under the GLP-1 RA section for glycemic control. Rybelsus (oral semaglutide) is covered under a separate entry.

Policy effective April 16, 2025 · verified June 4, 2026 · source: Diabetes-Mellitus-Type-2-Agents-PDF

Kansas Medicaid coverage for Ozempic (Type 2 Diabetes)